Provider Demographics
NPI:1821472226
Name:THEODORE, KELLY (PMHNP, FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W RAVINE BAYE RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1336
Mailing Address - Country:US
Mailing Address - Phone:262-308-7989
Mailing Address - Fax:
Practice Address - Street 1:930 E KNAPP ST
Practice Address - Street 2:STE 34
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202
Practice Address - Country:US
Practice Address - Phone:414-671-9355
Practice Address - Fax:888-376-4067
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6467-33363LF0000X
WI6467363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily